Tuesday, September 27, 2016

Building Better Metrics: Focus on Patient Empowerment

Growing up during the 1970’s and 80’s, the “Little House on the Prairie” television series was an iconic part of my childhood.  Doc Baker was the physician and veterinarian for all of Walnut Grove, in spite of limited resources.  Medical lessons were everywhere in the beloved television series:  Mary experiencing onset of blindness (most recently attributed to viral meningoencephalitis, likely from Measles), the death of Laura’s infant son by unknown cause, and Rose’s survival after smallpox infection.    

When patients ask me how to start solid foods, how to get a baby to sleep through the night, or how to treat minor injuries or burns, I frequently wonder if they would have asked the town doctor these same questions one hundred years ago.  Probably not, because they would know to watch their baby for hunger cues, let infants cry it out at night, or slap some egg white, aloe, or honey on their wounds or burns to prevent infection back then.  Empowering patients to treat themselves where appropriate has tremendous value to cut down on cost and consumption of precious resources.  It was also how medicine was practiced more than a century ago.

The other night I was reading comments of a local mom group on social media, when a question came up about how to treat thrush while breastfeeding.  A patient’s mother commented they should use gentian violet; paint their own nipples and their infants’ mouth lightly as well.  A mom asked, “What is gentian violet?” This mother discussed its antibacterial and antifungal properties and its topical use for oral candidiasis.  I felt a huge sense of pride watching her share knowledge with other mothers.  The cost of a 1oz. bottle of gentian violet is currently $3.69. 

Crystal violet (aka gentian violet) was first developed in 1883 by Alfred Kern; it is still listed today by the World Health Organization as a valuable topical antiseptic agent.  Gentian violet has antibacterial, antifungal, anthelminthic, and antitrypanosomal properties. Today, it is used for:  Marking the skin for surgery preparation, treating Candida albicans and related infections, such as thrush, yeast infections, tinea, jock itch, ringworm, and even Impetigo, primarily before the advent of antibiotics. Educating mothers on thrush and the use of gentian violet occasionally helps them avoid seeking care when unnecessary. 

Patient-centered care is often talked about as a virtue worthwhile to attain because it puts them at the heart of their healthcare team.  Empowerment goes one step further by actually giving power and authority to the patient.  It is a very important concept that is often missed in the world of big-box medicine today.  There is actually an organization devoted to this concept called the European Network on Patient Empowerment (ENOPE.)  According to them, an empowered, activated patient:

  • Understands their health condition and its effect on their body.
  • Feels able to participate in decision-making with their healthcare professionals
  • Feels able to make informed choices about treatment.
  • Understands the need to make necessary changes to their lifestyle for managing their condition.
  • Is able to challenge and ask questions of the healthcare professionals providing their care.
  • Takes responsibility for their health and actively seeks care only when necessary
  • Actively seeks out, evaluates and makes use of information.

Empowering patients to care for themselves with shared decision making is the reason my doors are still open.  Fee-for-service can be a fiscally valuable model because for one office visit, a patient can receive diagnosis, treatment, and education from a single professional.  Physician ownership encourages patient empowerment because it prevents doctors from spinning their wheels needlessly.  There is no benefit to seeing a patient over and over for the same chief complaint. We want our schedule open for other patients who need our help.  To avoid the journey overwhelming burnout, we need to lighten the load in our offices. 

Over the last century, health care has morphed from a system valuing individual responsibility to one grounded in physician dependency.  Patients are viewed as clients who ravenously consume scarce resources, while physicians dispense answers and guidance for a price deemed too high by bureaucrats to be sustainable.  Knowing how invested patients are in understanding their conditions and their willingness to take responsibility for their good or bad choices are metrics worth tracking. It is important to remember physicians make recommendations, educate their patients, and would do best by engaging in shared decision making with those patients.  That entire process saves money and improves how patients view their quality of care. 

A 3 year old girl came in with a history of 3 days of vomiting this week.  “I have been pushing oral rehydration solution with a syringe like you taught me,” she said.  Her mother knew how to check for signs of dehydration using urination frequency and a few other tricks I have taught over the years.  She knew when vomiting persisted in spite of proper rehydration attempts, it was time to bring her daughter in for evaluation. Her child had lost less than 0.5kg due to her mother’s excellent care and diligence.  I could not have been more proud and shared that with her.  At this point, it was reasonable to prescribe her a medication to reduce nausea and vomiting, but no ER visit was necessary because this mother had confidence in her skills to care for her child properly, and if she needed her PCP, she knew I would be there. 

Better metrics must be about being better able to empower our patients.  They are tired of being told how to birth their children, how to immunize them, how to lose weight, quit smoking, or exercise more, and how to treat their elevated blood pressure and cholesterol numbers.  I am not suggesting we stop sharing our expertise and making recommendations based on good science.  However, patients want to make their own informed choices and we need to let them.  Doc Baker had it right.  Take another look at his practice model in “Little House on the Prairie.”  A system incentivizing self-reliance is far more sustainable in the future and is where we should strive to be.

Wednesday, September 21, 2016

Broken Paint Brush and Foreign Bodies

The foreign objects may have changed over the past century, but the time-honored tradition of children getting them into small spaces has not.  Recently an article was published online about a display in the Ear Nose and Throat department at Boston Children’s Hospital with items removed from children starting in 1918.  The collection includes a screw hook, a sardine tin key, Scottie dog button, and even a political pin for FDR removed from an esophagus.  The display is a tribute to the late ENT physician who worked there for 35 years and removed the majority of the items on display. 

Children commonly stick odd things in their ears and noses or swallow toys not meant for ingestion.  My father’s favorite story of a swallowed foreign body involved ingestion of three OPEN safety pins.  He spoke to a specialist at the local children’s hospital who said the items would pass through and no intervention was necessary. 

Many of you have seen the bulletin board behind my office door where I have kept all the items removed from throats, ears, nostrils, and other locations over the years.  Each piece is cleaned with alcohol before being labelled with a date, the patient name, and location of extraction.  As you would expect, there are a lot of ear tubes up there, but also beads, buttons, and even a pussy willow from a child’s nose.  Also Play-Doh, a micro-machine, and even a gum wrapper are tacked up there too.  

Nowadays, button batteries are more commonly swallowed and pose particular risk because the chemicals in them cause esophageal damage within a few short hours.  Other high risk objects in today’s world include latex pieces (from blowing up gloves or balloons), magnets, and those dishwasher detergent pods that are so popular and look like candy. 

Children with foreign bodies requiring extraction are usually between the ages of 2-7 and I suspect they are curious as to whether or not the item will fit in the space; they never think about the inevitable removal process.  They probably swallow coins or marbles for the same reasons; not thinking about the potential consequences.  Sometimes, the foreign object ends up in its unexpected location completely by accident.

About 10 years ago, I got a phone call from a close friend of mine while on her way to my house with her husband and 13 month old daughter.  Their little girl had been walking around with a child size paintbrush in her hand when she tripped and fell down.  She was crying from the fall and on the floor was half of the broken paint brush handle.  They found the other half of the handle in her nostril.  There was a little bleeding but otherwise she looked fine.    

I still remember the expression on their faces when opening my front door.  It was a mixture of fear, guilt (not that there should be any), and a little panic thrown in for good measure.  Both mom and dad had tears in their eyes.  Their little girl was crying too, though I am not sure if it was pain or fear in all the chaos.  She was awake, breathing fine, and looked stable. 

She did indeed have a portion of a pink plastic paintbrush handle up her nose.  My brother was staying with me at the time and it was helpful to have another strong person present and able to assist.  I do keep some basic tools at my house for times when this issue comes up.  Over the years, I have removed stitches, given shots, and reduced a few nursemaids’ elbows at home too.  You just never know who or what might knock on your front door. 

I got a pair of tweezers out of the bathroom.  We laid her down on my kitchen counter and two adults held her down as I grasped the handle and removed it from her nostril.  It was much longer than expected, my brother swore during the process out of surprise, and at last the paintbrush handle was successfully extracted (to be later mounted on my bulletin board.) 

There are a lot of satisfying things we do as pediatricians and this is definitively one of them.  As physicians, we need a few tools at our disposal including a thermometer and stethoscope, but a location where we can lay a child down flat with good lighting is priceless.  I discovered the real value of my kitchen counter that night and it has seen a lot of exciting things since then.  

Tuesday, September 13, 2016

How Do We Teach Resilience to Our Children?

Teaching resilience is an important life lesson for children.  It is hard to know when or how to best impart this knowledge.  I suppose some things just happen by accident and I guess that is as good enough a way as any other.  
My oldest son entered the second grade this fall and changed to a new school.  He had the option to ride the bus or have me drop him off and he chose the more independent route, the school bus.  We received a call letting us know the bus stop location and a rough 8:20am pick up time.  Transportation was unable to give us a driver’s name or bus number yet, which was alright, how hard could this bus-riding thing be after all? 

On the first day, my 1st and 2nd graders were awake at 4:15am asking how long it was until they could leave for school.  I promptly escorted them back to bed letting them know it was not yet time.  At 7am, my oldest was dressed, with his lunch packed, school shoes and jacket on, begging to go wait at the bus stop more than an hour ahead of time.  We finally arrived at the bus stop at 8:15am and one bus #79 drove right on by.  We started wondering if that was ours as we stood waiting because no other bus drove up until 8:30am.  When it stopped, my husband and I did not doubt for a second this was the right bus.  My son eagerly ran across the street, got on the bus, and it drove down the hill. 

Unbeknownst to me, he arrived at the wrong school that morning and knew it when they pulled up to the front of Brownsville Elementary School in Bremerton, WA.  He let Glenda, the bus driver; know he was supposed to be at a different location.  She radioed for permission to take him to his proper elementary school in Silverdale, which is the one he intended to reach that day. 

According to my son, he and the driver got off the bus to hand out some information packets to teachers; they divided and conquered.  He covered three classrooms and she covered three classrooms.  After their work was complete, they boarded the bus to head to the correct location.  It was probably a 15 minute drive and during that time my son was just as observant as he always is.  He told me all about the things that went wrong with transportation that morning in the school district.  He said, “Mom can you believe one bus driver forgot half of her route this morning?”  He started laughing as he continued on, “some kids were running down the street chasing after the buses they missed, can you imagine if that happened to me?”  Well, no.  I don’t want to imagine that right now, thank you very much. 

Indeed, he arrived at the school around 9:30am (start time 9:10am) so altogether, not a total disaster.  Here is the interesting part.  I heard this whole story at 4pm after I picked up my son from school.  The last thing I knew, he was on the bus and attended a full school day.  Transportation was not aware of what happened.  The Elementary school did not know this happened either just assuming the bus was running behind.  His teacher knew his arrival time which is how I traced his movements that day roughly backward from there after the fact.  A librarian friend of mine did see him at the wrong school, but I did not hear about him looking lost until much later. 

I did speak with transportation and was given the proper bus drivers’ name and bus number later that evening, which in hindsight, would have been two helpful pieces of information to have.  His second day was uneventful as he boarded the proper bus and arrived at the correct destination.  Either way, thinking back on this past week helped me appreciate how resilient my oldest son has become.  In reality, he thoroughly enjoyed his exciting adventure regardless. We pass Glenda and her bus driving home from school every once in a while and each time, he enthusiastically waves at her with a big smile on his face. 

There are fewer opportunities today when our children are left to their own devices to problem solve; so while he did have some help from a wonderful bus driver named Glenda, his own resiliency played a large part in getting him to where he needed to be.  After the surprise wore off, I ended up proud of him and his growing resourcefulness.  Also, I am truly grateful to Glenda, the bus driver who, literally and figuratively, went the extra mile for my darling son. 

Sunday, September 11, 2016

I Wish My Patients Knew…

Referencing a recent New York Times article “What Kids Wish Their Teachers Knew” got me thinking about both sides of the coin.  Physicians are human beings and sometimes this fact gets lost when a patient is angry or frustrated seeking help from the medical system.  Here is a primer on what I wish my patients knew. 

I Wish My Patients Knew… My children started vomiting at 4am and I am completely exhausted. This happened about a month ago.  My third child threw up all over my clothes as I was leaving the house to drive to work.  I ran inside and quickly changed.  I put on flip flops at some point during this process and forgot to take them off as I ran out the door.  All day I walked about looking like I planned to go to the beach instead of the office and felt ridiculous plus I think I smelled like vomit as well. 

I Wish My Patients Knew… How privileged I feel to be an integral part of their lives.  Ours is a relationship forged in give-and-take conversation and in the sharing of knowledge built over decades that is difficult to replicate in any other profession.  I have seen so many poignant moments over the years reminding me of how fragile the human condition can be.  It is truly an honor to know my patients and their parents intimately sharing in their triumphs and tribulations.

I Wish My Patients Knew… I did not get paid this month.  At least once per week, a parent calls to ask if I could write off the cost of a procedure that was kicked over to deductible by their insurance.  Often they ask reasons a co-pay was charged with a well child exam when they brought a list of 15 questions about asthma, night terrors, food allergies, or a variety of other conditions requiring a prescription.  I have never said this out loud but really wish they could understand that I use my income to pay my mortgage and buy food for my own children.  At least one month each year out of the last 5, I did not receive a paycheck. 

I Wish My Patients Knew… How frustrating working with insurance companies can be.  These third party payers control the entire system except for the part controlled by the government.  Calling to obtain prior authorizations from someone who knows nothing about the medication I have prescribed drives me insane.  There are many people wedged between me and my patient, yet I shoulder the responsibility for decisions over which I have no control. 

I Wish My Patients Knew… The greatest thing about being a pediatrician is seeing my patients become adults.  Watching these tiny newborn infants grow up to be healthy, well adjusted, productive members of society are the stuff of which dreams are made.  Watching my patients become mothers themselves has truly been one of the most rewarding experiences of my life.  

I Wish My Patients Knew… How hard it is to make it through the day, week, and month when I have lost a patient unexpectedly.  A 12 year old girl who I deeply cherished died last year due to Influenza A.  I attended her delivery and held her in my arms before either her mother or her father.  She, like many of my patients, was very special to me.  This young girl was the first person who “informed” me my third pregnancy was a girl, despite my being resigned to delivering yet another boy.  She just knew it in her heart and she was right. I think of her every day, miss her smiling face and joyful demeanor, and occasionally catch myself hoping she will walk through my door. 

I Wish My Patients Knew… How hungry I am, how badly I need to urinate, or how much I need a moment to think.  There have definitely been days where I walk in to the examination room and want to dive into the bag of chips or fruit snacks my pediatric patient is eating.  Sometimes, I ask for a bite or two when I know them well enough.  It might be all I have to eat that day.   A bladder can clearly be trained to withstand a great deal of pressure and if you ask any physician, they would concur with this awkward ‘situation’.  When a frustrated person yells and curses at me, it is difficult to put aside; it would be fantastic to have a few minutes to collect myself rather than having to move on to the next patient and pretend everything is normal.    

I Wish My Patients Knew… I am late because an infant stopped breathing in the next room and I had to call an ambulance after resuscitating him.  I am still shaking and about to burst into tears out of fear the child will not survive the 45 minute ambulance ride to the nearest hospital that admits pediatric patients.  Your time is valuable and I mean no disrespect, but I am doing the very best that I can to stay on schedule.  That patient was in for a well child exam.  The respiratory arrest was purely coincidental and unexpected.  Some of my patients can read my face so well.  They say “take some deep breaths doc, we can wait”… I love and appreciate the sincere compassion shown at times like these.

I Wish My Patients Knew… It makes my day if you bring something.  Food is my favorite because it means I can eat while saying “thank you.”  Over the years there have been pictures, donuts, cards, coffee, flowers, farm fresh eggs, homemade jams, fruits, chocolate, music boxes and the list goes on.  It has nothing to do with monetary value; it is the sentiment I appreciate.  It tells me you understand I am giving my all, doing my best, and not holding back on your care and comfort.  It means the world to me. 

I Wish My Patients Knew… I would not change anything about my career choice.  Being a physician was my calling from the time I first entered a hospital nursery with my father at 5 years of age.  I knew it then as sure as I know it now.  Primary care comes with an unbelievable amount of responsibility, stress, exhaustion, and frustration; but there is also overwhelming joy, fulfillment, gratitude, freedom, and love.  I could not be more proud to be a physician and there is no other profession in the world that is more rewarding than mine. 

Sunday, September 4, 2016

I Wish My Doctor Knew…

Recently the New York Times published an article What Kids Wish Their Teachers Knew.  As a pediatrician, I have spent a good part of my lifetime fighting for the health and welfare of our young people.  They are the future.  We owe our children a safe, caring, stable childhood whenever possible. Outside of a supportive family, a long-term family physician or pediatrician can be an important role model for impressionable youngsters.  For confidentiality reasons I have altered identifying details, but will give you some of the great things heard over the years and a few tragic ones as well. 

I Wish My Doctor Knew… There is not enough food at home.  Many years ago, I was seeing twins for a yearly checkup and giving them shots when one, older by 4 minutes, blurted out there was not enough food to eat at night when she was hungriest.  I contacted the school counselor to ensure both children were offered free breakfast and lunch at school.  They were added to the program sending home a backpack full of food every weekend.  At Thanksgiving, this family received one of the donated dinner baskets with turkey, mashed potatoes, and all the trimmings.  The children grew better and crossed percentiles in the positive direction; their grades improved as an added bonus. 

I Wish My Doctor Knew… I want to marry her someday.  A six year old boy informed me he was going to “marry me” when he grew up.  He was disappointed at 9 years of age when I married my husband.  He turns 18 this year and brought his girlfriend to the last visit which seemed awkward initially until she confessed I took care of her as a little girl more than a decade ago.  I definitely approved.

I Wish My Doctor Knew… My mother is drunk right now. When I smell alcohol on their breath, they should not drive themselves home.  Often there is a companion with them who is a designated driver, but if high on methamphetamines or intoxicated, I call the authorities, trying to distract the parent until help arrives. 

I Wish My Doctor Knew… I want to be just like her when I grow up.  I have this budding group of young future physicians.  They come with me when I draw up shots to “help”; many of them look forward to our time together.  The conversations while standing next to the immunization refrigerator are unbelievably candid.  After turning 16, I encourage them to follow me for a week and determine if medicine is really something they are interested in pursuing.   

I Wish My Doctor Knew… my daddy does not live at home anymore.  This one comes out unexpectedly every so often.  Parents have a hard time telling me because they are afraid I will be disappointed in their decisions.  I remind my families it is not possible to know what any of us would do ourselves until faced with the exact same circumstances, experiences, and entanglements. We are all doing the best we can. 

I Wish My Doctor Knew… How much I hate her right now.  This is my favorite kind of teenager.  Their statement usually follows startling recommendations for enforcing a curfew, punishing for smoking pot in their bedroom, removing computer or cell phone access due to failing grades, or unexpectedly curtailing their activities.  The angry teenager crosses their arms, glares at me, and tells their parent they are never coming back to this awful place.  I smile and tell them eventually they are going to love me, but until then, they need to be patient and give it time.  They shoot me a look that says, “Want to bet?”  It is a challenge I readily accept.

I Wish My Doctor Knew… I am scared of being deported.  A few weeks ago, a child said they were worried about who was going to be elected, because they were afraid of being sent back to El Salvador.  I asked if he was born in the US and he replied he was but his parents were not and he was afraid they would be sent away.  He is just seven years old.  I honestly did not know what to say. 

I Wish My Doctor Knew… I love when she has time to read me a story.  Once in a while, I get a break in my schedule and children will ask to have a story read to them.  I love reading to children.  I never read it the same way twice.  The shared time and resulting connection is absolutely priceless. 

I Wish My Doctor Knew… My uncle got me pregnant.  This has remained one of the most difficult situations I have ever experienced in my career.  Physicians face unexpected situations often but witnessing the consequences of depravity can be utterly devastating.  She looked much younger than her twelve years, yet delivered a healthy infant a few days shy of thirteen.  When I asked her if she had been sexually active, she answered ‘no’.  She was telling the truth because of course, she did not consent to what was done.  After transferring her to an alternate location for necessary medical care, I vomited into a garbage can before calling CPS and the police. 

I Can’t Wait to Tell My Doctor…I got straight A’s on my report card.  When kids come in beaming while holding up a piece of paper, I know it is going to be good.  It can be a college acceptance letter, certificate of achievement, or a sports award they earned for their hard work and dedication.  I like to make a copy and place it in the “friendship section” of their chart for posterity sake.  It is such a pleasure to watch a child revel in their own success. 

While this job is difficult beyond imagination, what I love about being a pediatrician is seeing how resilient children are despite the obstacles they face.  We do not give them enough credit sometimes; they are far stronger than we realize.  It only takes one adult who was supportive and willing to make sure the needs of the child were met to change the trajectory of their entire lives.  I have seen it, I have done it, and I will continue listen, encourage, support, and love these young human beings.   Be that one adult when a child in need crosses your path. 

Friday, September 2, 2016

Spanking and Science Part 4: Conclusions

This is the fourth and final installment of Spanking and Science, if you missed the others or would like the hyperlinks for studies, please look back to parts 1,2, and 3. 

Dr. Mark Roberts at Idaho State University has conducted the only four randomized controlled clinical trials of physical discipline ever done.  His goal was to determine the single best intervention for reinforcing discipline after a child’s escape from time-out.  A spank method (similar to the other researchers) was tested against 3 other interventions, barrier (room time out), holding, and release (allowing escape from time-out). 

The most effective methods were the spank and the barrier methods.  The spank procedure involved two open handed swats to the rear end and then returning the child to time-out.  The barrier method involved taking the child to a small 4x5 carpeted room and barricading them inside with a sheet of plywood for a brief period of time, then placing the child back in time-out. The other two methods, holding and release were far less efficacious. 

Though spank and barrier were clearly the most effective measures used, parents preferred the spank method in the home environment (64%.)  The room requirement for the proper barrier punishment was not as practical for parents.  Others have attempted to repeat portions of these randomized clinical trials and have reproduced the results:  “mild spanking is the most feasible back-up for the child who leaves time-out” according to Forehand and McMahon (1981.)

Roberts’s studies are significant for many reasons.  They are the type of study that enables definitive conclusions to be drawn.  Furthermore, they compared spanking to other methods of discipline thus answering the million dollar question as to the effectiveness of spanking in a specific situation.  Spanking is clearly effective in changing problem behavior.

Non-compliance with time-out is similar to other defiant behaviors a child may initiate such as biting, refusing to comply, hitting, or running away.  Spanking strengthens compliance with time out, a crucial part of its effectiveness, and reduces the need for spanking as primary punishment method in the long-run.      

In conclusion, the question as to whether it is beneficial to spank or not to spank a child has not been definitively answered and additional studies would be helpful.   Currently, across the country, pediatricians and psychologists are split 50-50 on the value of spanking as are parents meaning there are no easy answers.  The main studies reviewed over my four posts included those conducted by Drs. Larzelere, Baumrind, Gershoff, and Roberts as they are considered to be experts; all with differing opinions of their own.

Parents need MORE disciplinary options, not less, to maximize the flexible use of non-abusive alternatives. Personally, after reviewing the literature extensively, I would suggest a few nuances to my original article.  Parents should switch disciplinary tactics when the initial one is not working, rather than increasing the intensity of the first tactic as there is solid science to support this very important recommendation.  Spanking is most effective when used between the ages of 2-6 and should begin phase out as a child turns 7.  It is strictly defined as two swats to the buttocks with an open hand.  A good benchmark if using spanking as discipline would be less than three times per week. Finally, it is not a recommended tactic for use with teenagers (not surprising.)

Research does not support the use of an object and in general, that would not be my automatic recommendation for everyone.  However, I do use a wooden spoon and would like to comment on that specifically.   For me, picking up the wooden spoon is my signal to calm down and not strike in anger.  This action makes me stop, take a deep breath, and think about whether or not a spank is truly necessary and warranted given the circumstance.  Often, I simply put it down and try something else.


All four of my children are 7 and under at the present time, so I am literally in the thick of the very age group covered by most studies on physical discipline.  I learned a great deal delving into the scientific details and I sincerely thank all of you for joining me on this journey. 

My recommendations unknowingly echoed what the research already supports by trusting my instincts, and I believe it is vital for parents to trust themselves and do what feels appropriate.  All of us can learn more about parenting, this pediatrician included. I hope as a parent yourself, you feel more confident in whatever discipline decisions you do make.